As a young girl in New Dehli, India, Harpreet Gujral, MSN, FNP-BC, INC, grew up knowing medical practitioners of all stripes. Depending on the illness, her parents took her to a conventional medicine physician, a homeopathic doctor, and even an ayurvedic (ah-yur-ve-dic) practitioner. By blending those approaches, they not only exposed her to her future profession—she loved the nurse’s white cap and uniform—but also to a mix of holistic health practices.
So when an e-mail about a nurse coaching program crossed her computer screen in 2011, Gujral took a close look. After two decades as a nurse and nurse practitioner, primarily with Inova Health System in Fairfax, Virginia, she was intrigued by the idea of returning to the holistic concepts she had set aside years ago to fit into this country’s Western health culture. As a nurse coach, she’d no longer be the “expert” voice telling individuals what to do. Instead, she’d be guiding them to their own conclusions, on their own timetables, with their unique stories front and center. In short, this would be about treating the whole person.
“I realized that my roots were calling me,” Gujral says. “I’ve always taken pride in how I treat my patients and their families, but I also know that there’s room for improvement. There’s always a little bit more I can do in the way I practice. This holistic approach offered me that opportunity. It also took me back to my Eastern roots.”
Perhaps you hear the same call. After years of dispensing care the traditional nursing way, you’re open to a practice approach that moves patients toward optimal wellness and even lifesaving self-care without suggesting a “fix.” Nurse coaching offers those opportunities. As detailed in a recently published American Nursing Association (ANA) textbook, The Art and Science of Nurse Coaching: The Provider’s Guide to Coaching Scope and Competencies, this approach puts patients (or clients, as they are often referred to) in charge of their own care by letting them direct the activity and pace.
“As nurses, we’re great at telling people what to do,” says Barbara Dossey, PhD, RN, AHN-BC, FAAN, co-director of the International Nurse Coach Association (INCA), and a coauthor of the book. “But the beauty of nurse coaching is that we’re no longer fixing things. Instead, we’re helping clients really look at their situation, tap into their own resilience, and be able to say, ‘I can try that. I can do that.’”
Patient First Is Fundamental
But with a relationship-centered focus as the goal, what do nurse coaches specifically do to change the dynamic? And what constitutes the art versus the science? The short answer is that coaching actually expands the role of nurses and nurse practitioners by integrating the scientific, scholarly based skills they learned in nursing school with a bevy of new aptitudes and theories to help them guide individuals holistically on the road to wellness.
To be successful, nurse coaches accept two fundamental beliefs: First, people are unique persons in their capacity to learn, develop, and change. When invited to direct their own health, they’re very capable of positively impacting their progress. Second, nurses can play a primary role in mobilizing someone’s innate capacity for such growth and self-healing. By establishing a deep connection and true collaborative relationship—one in which they’re willing to be led rather than always leading—nurses are uniquely positioned to guide any individual in realizing his or her wellness potential. That means any specialty, any setting, and any condition—acute or chronic—that might benefit from behavioral change.
But how does one navigate the relationship with clients so they’re inspired to take even preliminary steps toward renewed health? For starters, rather than offering your educated opinion and advice, you should:
• Encourage people to be experts in their own care. That means accepting them unconditionally where they are in terms of their lives and health issues while giving them wide berth to identify their own priorities and areas for change. You may not share someone’s values or decisions, but by honoring this person’s uniqueness, you encourage a course that truly reflects his or her belief system and way of doing things. In short, you recognize that change is best achieved when it comes from within and fits someone’s readiness, desires, and goals.
• Emphasize human caring in each encounter. Although this concept is a moral ideal in all of nursing, it’s particularly important when the goal is to assist someone in his or her wellness journey. Human caring requires that you’re fully present and nonjudgmental. It means creating a safe environment in which people can freely express their hopes, dreams, fears, and pain, knowing that such information will be met with empathy and respect. In short, regardless of their current vulnerabilities or choices, your clients can be confident that you’ll be supportive as they evolve toward healthier goals.
“Before I was trained in holistic nursing, I approached patients as dependent persons in need of services, guidance, and resources,” says Margarita Ruiz Severinghaus, RN, MA, AHN-BC, HWNC-BC, clinical resource coordinator at the Office of Care Management for Dartmouth-Hitchcock Medical Center, based in Lebanon, New Hampshire. “It was a one-dimensional approach to care. But as a holistic nurse coach, I have a much broader perspective of the whole person. I’m much more aware of the multiple dimensions involved in this individual’s entire experience.”
Where Art and Science Merge
Eliciting your client’s health story and goals entails a level of inquiry that goes deeper than a traditional patient-provider interaction. Some of the skills you’ll weave throughout each encounter come from the counseling and psychology worlds. Others may even touch on behavioral and other principles you learned first in training.
In nurse coaching, your objective isn’t to analyze a current problem, judge a previous failure, or even dig archaeologically for old issues. You’re also not there to “fix” the clinical diagnosis at hand. Since this approach is about raising a client’s health consciousness and general awareness, you’re focused on where that person is right now in generating achievable goals. That may include, for instance, helping a midnight-shift worker realize better options to quality health than hitting the all-night deli because it’s an easy stop between the subway and home.
“One of the strongest principles in my approach to nurse coaching is cultivating awareness because that allows you to make choices,” says Bonney Schaub, RN, MS, PMHCNS-BC, cofounder of the Huntington (NY) Meditation and Imagery Center, and coauthor of the ANA book. “People often don’t realize that something is a habit until you say, ‘Let’s look at the steps that go into this.’ Once they become aware, however, they can create a plan to choose differently.”
Whatever you do, you want to create positive energy—or ch’i—by listening attentively, engaging skillfully, and most importantly, following your client’s lead as he or she determines the direction of each session. It’s in these exchanges that the art and science of nurse coaching converge. Of course, you’re still going to utilize the scholarly-based, critical thinking and systematic processes you learned in nursing school. The same can be said for the competencies, professional standards, and core values. They’re as fundamental to the science of nurse coaching, as are the communication skills you’ll need to break through barriers and keep people on track.
The art of nurse coaching refers to how skillfully you maneuver those tasks along with additional aptitudes and tools you’ll use to address the body-mind-emotion-and-spirit connection of an integrative or holistic health experience. It also suggests the nuanced adjustments you may have to make during each encounter. In that way, the art of coaching is much like the art of dance. Both require that you know when to lead in one direction, when to follow in another direction, and when to change directions, depending on any shifts in energy. So how does that occur? As Darlene Hess, PhD, RN, AHN-BC, PMHNP-BC, ACC, HWNC-BC, founder of Brown Mountain Visions, a coaching firm based in Los Ranchos, New Mexico, and coauthor of the ANA book, observes: “You develop an inner ability to trust yourself to be in that quiet place where you may not have a clue as to where to go next or what to do next. Yet you remain still and present, allowing that knowing to emerge. Then, as it does, you and your client dance together with it. That’s the art.”
In practical terms, you’re relying not only on that intuition, but also on a bevy of other modalities—guided imagery, meditation, and art therapy on the list—to help clients discover and win their goals. But for starters, you’re just mindfully present with the person. That simply means that you’re focused entirely in the moment on what this individual is saying with no preconceived notions as to what that conversation might yield. To do so, you’re engaging in:
• Deep listening plus the power of the pause and not knowing. By concentrating intently, you’re not only creating a safe space where your client can deepen his or her own awareness, but you’re also allowing yourself to hear this person’s story. Perhaps it’s the woman whose spirit is broken after losing everyone she loves. By cultivating your deep listening skills, along with additional tools such as the power of the pause and not knowing everything, you’re able to explore territories with her that might otherwise remain unknown or untouched. Deep listening also permits you to pay attention to body language, which sometimes speaks louder than words. “If somebody is ready to cry, I’m not going to interrupt where he or she is at that moment,” says Dossey. “I’m going to hold that space and just allow this person to go with it.”
• Motivational interviewing and appreciative inquiry. Used in tandem, these techniques are foundational in your efforts to draw out individuals, accept what they’re saying, and encourage them to reach their own conclusions. Motivational interviewing, for instance, is about valuing change. It’s about getting a middle-aged man to understand that taking his blood pressure medication every day is important, even if it didn’t seem so in the past. You’re not trying to scare this person with the arithmetic of unchecked hypertension and silent strokes. Instead, you’re searching—through the co-technique of appreciative inquiry—for clues as to your client’s best strategies and strengths. Perhaps in the end that means simply suggesting, “Is it possible to set the pills at your bedside with water and make them part of your morning routine?”
• Open-ended questions. The tools that drive every encounter, open-ended questions allow you not only to engage people in decision-making, but also to gather important intelligence. The beauty of this technique is that you can use it no matter where your client sits on the willingness spectrum. For instance, if he or she is just contemplating the possibility of eating healthier, sleeping better, or even getting off drugs, you open the conversation by asking, “Is this something you might do in the future?” or “What might be some of the barriers to starting now?” Or, if your client is edging toward action, you might nudge things along with: “Can you imagine what change might look like?,” “Can you think of how you might accomplish it?,” or “Are you willing to do it in the next six months?” You know your client is finally ready for real action when he or she mentions an immediate goal, eager to strategize steps for meeting it.
How long might that transition take? It’s hard to say what triggers someone from merely thinking this could be a good idea to saying, “I’m ready to take action.” Perhaps a wake-up call—a family member getting sick or a news story generating a scare—suggests that the time is right. It’s also difficult to assess what obstacles or new issues may emerge and intrude along the way. Daily habits, cultural practices, or even a worldview suggesting that the course of health events can’t change because that’s what God or nature intended can be overwhelming. Likewise, your client may experience a more immediate issue that forces a course correction from the long-term plan to the problem at hand. Perhaps she’s afraid to go home, for instance, because an abusive husband is waiting.
Whatever attitudes, ingrained beliefs, socio-economic circumstances, or life challenges are creating roadblocks, probing questions and deep listening allow you to guide someone in overcoming them. Whether you’re asking your abused client for permission to offer resources that might keep her safe or you just want to know what’s the “worst” and “best” case scenarios for taking off excess weight, you’re continually gauging this person’s readiness.
“As nurse coaches, we sometimes feel responsible for the timing,” says Dossey. “But if we’re truly going to have a patient-centered focus, we’ve got to acknowledge that it’s someone else’s life and someone else’s choice. We can create the opportunity for change, but we can’t force people to take it. Anyone who has raised children will confirm that.”
Building Success on Strengths
Whatever the timeline, when the opportunity presents itself, nurse coaches pivot to options that build on someone’s strengths rather than emphasize his or her weaknesses. Since the very premise of this approach is to praise or encourage people to success, you’ll likely be helping your client enlarge his or her strength vocabulary by identifying all of the traits that he or she has relied on in the past. Keep in mind, however, that people often don’t recognize the true virtues in their own story or what they’ve accomplished previously. The efforts seemed so small. The tasks were so large. Or the relapses have been too many in number to appreciate that just being open to a new attempt is evidence of progress.
Whatever the challenges, the big goals for your client may be incremental at best:
“I’ll walk to the mailbox.”
“I’ll add vegetables to my dinner.”
“I’ll reduce my salt intake.”
“I’ll give up half a pack of cigarettes each day.”
Even a heroin addict’s willingness to stop sharing needles can be a lifesaving behavioral change. This person may not be ready to give up drugs, but he or she is at least willing to consider the transmittal risks of infection. “It’s not necessarily going to be everything that you want for them,” says Gujral. “But just making strides in the right direction and seeing the value of those strides, even quantifying them, will keep them moving forward.”
After overhearing a pre-op nurse practitioner scold one woman for having horribly high blood sugar levels for someone facing immediate cardiac surgery, Gujral decided to draw attention to the positive news during her subsequent diabetes consult. She parlayed her motivational interviewing techniques by focusing on how her teacher-client had accomplished a 2% decrease in her hemoglobin A1C test from results over the past two years. With a double take and a smile, the woman related that she just had made a concerted effort to eat healthier, despite the difficulty of living alone with no support system.
Knowing that the levels should improve even further, Gujral followed with: “What do you think would allow you to get an even better result?” The woman offered that she’d examine her after-school schedule to see how she could incorporate more activity and a healthier eating plan. Then came the negotiation. Gujral thought her suggestion of walking 10 minutes around the house after dinner was a perfect pitch idea. But as to the TV dinners her client promised to eat each night, Gujral wondered aloud if there wasn’t another easy option with less salt. Perhaps heating mixed frozen vegetables, seasoned with olive oil, might be a doable alternative. “Would that be something that might work for you?” By securing a “Yes, I can do that,” Gujral gave her client options after surgery. “It’s really important for our clients to feel that they’re coming up with a plan that can work,” she says. “I’m available to embellish it, but not just as an expert. I’m using my coaching techniques.”
Whatever the strategy, you’re always mindful of the final leg—sustainability—of your coaching efforts. You’re not only guiding folks in realizing what they need to do to get unstuck, but you’re also helping them break down their objectives into small tasks that can be used over time. What else must be present for this person to keep things going long-term? Besides ready responses to that inner critic and habits that can thwart their efforts, they need to recognize the tactics that have worked for them in navigating other life issues.
Likewise, your client will decide how to measure success, based on the goals the two of you set up-front. Perhaps it’s to walk down the stairs without pain every morning or maybe dance at a granddaughter’s wedding next year. Whether true progress takes place within the context of your coaching relationship or much later, your role is to encourage the possibility and acknowledge every feat. More importantly, you want your clients to recognize and accept what they have accomplished, too! Since momentum builds on momentum, improvement on one goal can encourage targeting the next one. And even if the two of you can’t celebrate winning the initial objective, you can mark any strides that might lead to fruitful results later. “Nurse coaching doesn’t necessarily guarantee that your clients will be habit-changers,” says Severinghaus. “But hopefully this process of discovery will allow them to appreciate the effect of choice on their happiness and well-being.”
A nurse coaching relationship isn’t built to last forever, even if you really enjoy the interaction. Although the length of any commitment is based on someone’s needs and goals, there’s both a starting point and an ending point. Whatever the timeline, your goal is for your client to tap into his or her innate abilities to be empowered for a lifetime. Other medical practitioners likely have explained the stakes, and may even have referred this person to you. But you’re there to right the ship so it can sail.
In the meantime, you may find a deeply satisfying way to practice that connects you to your profession and patients in an exciting new way. For instance, when she answered that e-mail in 2011, Gujral found more than just INCA’s Integrative Nurse Coach Certificate Program. She was up close and personal once again with the holistic health concepts she had first learned in her native India—only now they’re an integral part of her day. As assistant director of certifications services at the American Nurses Credentialing Center (ANCC) as well as a private hospitalist practice nurse practitioner, Gujral has found ample ways to use her nurse coaching skills. Whether she’s collaborating with ANCC staffers or guiding patients to better medical results, she delights in coaxing people to do their best. So inspired by nurse coaching as a path to wellness, she’s even pursuing a doctoral degree in nursing practice, focused on integrated health and healing.
“I’ve always taken pride in being a nurse,” Gujral says. “But my satisfaction with my profession has gone up many notches since I became a nurse coach. Making the connection with people at such deep levels is amazingly fulfilling. It gives me great joy.”
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